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How and why do countries vary so much in their use of health services?

Adam Wagstaff's picture

I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

What exactly is the public-private mix in health care?

Adam Wagstaff's picture

I’ve been in quite a few meetings recently and read quite a lot of documents where people have made claims about the relative sizes of the public and private sectors in health care delivery. A recent report from the World Bank Group on the private sector in Africa claims that “the private health sector now provides half of all health services in the region.” A document I reviewed recently claimed that “much” of medical care is provided by the private sector – an assertion I hear quite often.

As far as I can make out, the data underlying such claims reflect a very partial picture. The Africa data are from the Demographic Health Survey which captures only treatment for (outpatient) maternal and child health services (MCH); it also covers only the developing world, and only the poorer part of it. Some claims reflect data for just one country. I’ve heard a lot about India, but these data (obviously) cover just India, and only outpatient visits.

The Academic Sting Operation

Adam Wagstaff's picture

Nobody likes to be stung. Doctors regard it as unethical. Publishers say it betrays the trust of their profession. But the fact is, as three recent studies have demonstrated, sting operations can be extremely effective at exposing questionable professional practices, and answering questions that other methods can't credibly answer.

Sting #1: Are open-access journals any good? 

Much of the world has gotten fed up with the old academic publishing business. Companies like the Anglo-Dutch giant Elsevier and the German giant Springer earn high profit margins from their academic journals (Elsevier earns 36% profit, according to The Economist), through a mix of ‘free’ inputs from academics (the article itself and the peer-review process) and high (and rapidly rising) subscription charges that impede access by academics working in universities whose libraries can’t afford the subscriptions. Of course, many of these universities paid for the authors’ time in the first place, and/or that of the peer-reviewers; tax-payers also contributed, by direct subsidizing universities and/or by the research grants that supported the research assistants, labs, etc. Unsurprisingly, libraries, universities, academics and tax-payers aren’t happy.

Health and the post-2015 development agenda: Stuck in the doldrums?

Adam Wagstaff's picture

I think it’s fair to say most of us don’t typically take UN reports with us on our summer vacation. But you might want make an exception in the case of the high-level panel (HLP) report on the post-2015 development agenda. It offers a nice opportunity to reflect how – over the last 15 years or so – we have seen some serious global shifts in values, expectations and motivations. 

The HLP feels the MDGs were worthwhile: “the MDGs set out an inspirational rallying cry for the whole world”. As my colleague Varun Gauri argues, goals inspire if they are underpinned by a moral case, and the panel pushes hard on issues of rights and responsibilities, social justice, and fairness: “new goals and targets need to be grounded in respect for universal human rights”; “these are issues of basic social justice. Many people living in poverty have not had a fair chance.” 

Hospital reforms in France: what can we learn?

Helene Barroy's picture

Hospitals in France deliver services for acute care. Except for surgery, the consumption of hospital care is predominantly public. The sector accounts for half of the national consumption of medical goods and services and is mostly funded through the Health Insurance system.

The public hospital sector has been facing recurrent deficits over the last three decades, associated with weak managerial print and uneven performance. Since the 80s, global budget was the norm, leading to rent seeking within and across public Hospitals in the absence of incentives for quality and efficiency. Thus, the French Government launched a massive reform initiative starting 2004 to strengthen hospital efficiency and quality of care in a resource-constrained environment.

Danger of a pandemic

Olga Jonas's picture

The following post is a part of a series that discusses 'managing risk for development,' the theme of the World Bank’s upcoming World Development Report 2014.

On February 15, 2013, an asteroid 45 meters across sailed past the Earth at 4.9 miles a second.  This was the closest encounter on record with an asteroid this big. Such rare events trigger fear because people overestimate the risk of unusual events – at least for a while. The odds of other rare events are often underestimated. People have a hard time understanding frequencies that are longer than a human lifetime; politicians discount probabilities of disasters that are unlikely to hit while they are in office and so they underinvest in prevention. In sum, we have trouble assessing low-probability, high-impact risks – the kind of events dubbed as Black Swan by Nassim Taleb. 

Responding to concerns about the asteroid, The Economist (Danger of death! Feb. 14, 2013) created a graphic to illustrate how we are unlikely to die from asteroid impact (odds of one in 75,000,000). The chart showed that more prosaic, but still rare, dangers were worse.  For instance, 27 people died in 2008 in America from contact with dogs (a one in 11,000,000 chance of death).  The ranking also showed the odds of death in any given year from a range of causes, such as heart disease, choking, falling down stairs, cycling, and bee stings.

Cost-effectiveness vs. universal health coverage. Is the future random?

Adam Wagstaff's picture

I've been blogging a bit about Universal Health Coverage (UHC) recently. In my "old wine in a new bottle" post, I argued that UHC is ultimately about ensuring that rich and poor alike get the care they need, and that nobody suffers undue financial hardship from getting the care they need. In my "Mrs Gauri" post, I used my colleague Varun Gauri's mother as a guinea pig to see whether the general public feels that UHC is a morally powerful concept and whether it could be expressed in a way that the general public would find accessible.

My sense from Ms Gauri's comment on the post, is that the answer to both questions could well be Yes. So far so good.

Some bad news—resources are finite

But before we place orders for colorful placards and huge banners with my suggested slogans "Everyone should get the care they need!" and "End impoverishment due to health spending!", we should break some bad news to Ms Gauri and the rest of the general public: resources are finite, and especially in poor countries the available resources won't allow us to get to UHC anytime soon.

So what exactly is the “science of delivery”?

Adam Wagstaff's picture

The World Bank’s president, Jim Kim, has now made two major speeches outlining his vision for the institution – one at the Annual Meetings the other at Georgetown University on April 2 ahead of the upcoming Spring Meetings.

Several themes are emerging. Two are easy to grasp and likely to resonate strongly with Bank staff and stakeholders: “ending poverty” and “boosting shared prosperity”. For years the Bank has seen fighting poverty as its mission. It has made major contributions in the areas of measuring and monitoring poverty – Bank staff have authored many of the world’s most-cited publications with poverty in the title. The Bank’s work at the country level has always had a strong anti-poverty focus. “Ending” poverty – rather than merely “fighting” it – is a natural next step. The idea of “boosting shared prosperity” also resonates. While economic growth is still seen as the principal driver of poverty-reduction, the goal has always been pro-poor growth – a concept that links naturally to the idea of “shared prosperity”.

The Impact of the Global Food Crisis on Self-Assessed Food Security

Derek Headey's picture

Has the rise in international food prices since the mid 2000s hurt the poor, or helped them? Until recently, everything we knew about this topic came from simulation analyses rather than survey data. Simulation approaches invariably predict that poverty and food insecurity increases as the result of higher food prices, but there are many reasons why these predictions might not eventuate. On the other hand, standard household surveys yield information only after  long lag periods. In light of these constraints, in some of my work I use an indicator of self-assessed food security from the Gallup World Poll (GWP). Since 2005, Gallup has survey men and women in a large number of developing countries and asked them (among other things) whether they have had “any trouble affording sufficient food in the last 12 months?” I take the percentage of respondents who answer yes to this question as a measure of national food insecurity.

Universal Health Coverage and the post-2015 development goal agenda. And Mrs Gauri

Adam Wagstaff's picture

In a recent blogpost I asked whether Universal Health Coverage (UHC) is old wine in a new bottle, and if so whether that’s so bad.

I argued that UHC is ultimately about making sure that “everyone – whether rich or poor – gets the care they need without suffering undue financial hardship as a result.” I suggested UHC embraces three important concepts:

• equity: linking care to need, not to ability pay;
• financial protection: making sure that people's use of needed care doesn't leave their family in poverty; and
• quality of care: making sure providers make the right diagnosis, and prescribe a treatment that's appropriate and affordable.